Sunday, August 23, 2009

American Values and Health Reform (3): Medical Progress

This is the third in a series of posts based on “Connecting American Values with Health Reform,” a publication of eleven short essays from The Hastings Center. The aim of the project was to consider what we want health reform to accomplish and to suggest what values our institutions and practices should be built upon, based on the belief that more clarity about underlying values would allow legislators and the public to handle reform more effectively. (See here and here for the two previous posts)

I hope legislators and media folks read Dan Callhan's essay on "Medical Progress: Unintended Consequences." The content will be familiar to those who have followed Callahan's work, but the short piece is provocative, clear, and easy to follow. It provides an ideal basis for a book club type discussion.

Callahan takes off from the observation that "a powerful faith in science as a basic human value, matched by an equally strong belief in medical progress, has been a central feature of American culture from the start." He acknowledges that we are "healthier and more prosperous because of it," but notes that the intensity of our faith in medical progress has put it off limits for ethical inquiry.

With that background Callahan lays out a series of concerns about the policy implications of our unquestioned faith in the value of medical progress:

New technologies or intensified use of older ones account for 50% of our annual health care cost increases. "Our technological benefit is turning into our economic bane." Callahan argues that we should do more assessment of cost-benefit ratios and make choices about what we want to pay for.

Much of the improvement we have achieved in health and longevity comes from improvements in socioeconomic factors - perhaps 60%. Callahan argues that "one could make a good case that improvements in education and job creation could be a better use of limited funds than better medical care."

Given his view that "throwing technology at illness in the name of progress is an increasingly expensive and economically destructive way to go," Callahan urges us "to aim for a better balance between cure-oriented and care-oriented medicine."

With regard to prevention, Callahan takes a very tough stand: "the only way to assure a good outcome for prevention programs is to make clear to the public that high cost technologies will be severely limited when the final illness comes. The carrot is that prevention will give us a longer life with a higher quality. The stick will be the message that you should take care of yourself and not expect medicine to save you when your time runs out."

As an extension of his comments about prevention, Callahan engages directly with longevity and mortality: "Americans already live, on average, a long life of seventy-seven years. There is no need to go out of our way to chase life extension, or the denial of death, as the sine qua non of medical progress. We need progress in removing the health disparities that keep millions from reaching seventy-seven..." Coming from a younger person this perspective would elicit a torrent of ageism accusations. Coming, however, from someone who, if online information is to be believed, will be 80 next July, Callahan's view may receive the thoughtful and respectful attention it deserves.

Callahan's tone is moderate, but his conclusions are radical:

Serious progress would mean turning back the clock: learning to take care of ourselves, to tolerate some degree of discomfort, to accept the reality of aging and death, and to see our personal doctor as someone as likely to talk with us as to have us scanned. That cluster of backward-looking ideas is what I think of as common sense, affordable progress.

I think most people who have given serious thought to the health system, including conservatives and people of faith, will agree with much of what Callahan says. But in the frenzy of anti-government sentiment that Republicans are fomenting, Callahan's views may elicit an "Aha - they really are planning for euthanasia" reaction from the Rush Limbaugh crowd. The level of political hysteria and public paranoia is so high that even a great communicator like the President would have a lot of difficulty working with Callahan's wise perspective.